The document discusses acute compartment syndrome, which occurs when increased pressure within a closed fascial space compromises circulation and function of tissues. Left untreated, it can lead to ischaemic contractures and disabilities. Compartment syndrome is diagnosed clinically based on pain out of proportion to injury, pain with passive stretching, and other signs. Intracompartmental pressure monitoring can aid diagnosis when clinical assessment is difficult. Early decompression of affected compartments through fasciotomy is key to preventing permanent damage; this is generally recommended when compartment pressure is within 30 mmHg of diastolic blood pressure.

1. ARTICLE IN PRESS
Current Orthopaedics (2004) 18, 468–476
www.elsevier.com/locate/cuor
EMERGENCY CARE
Acute compartment syndrome
S. Singha,Ã, S.P. Trikhab, J. Lewisc
a
7 Ardmay Gardens, Surbiton, Surrey, KT6 4SW, UK
b
Flat 3, 9 Grange Road, Kingston-upon-Thames, Surrey, KT1 2QU, UK
c
Worthing and Southlands NHS Trust, West Sussex, UK
KEYWORDS Summary Compartment syndrome can occur in any myofascial muscle compart-
Compartment ment. If left untreated it can lead to ischaemic contractures and severe disabilities.
syndrome; A high index of suspicion is required in at risk cases. Compartment pressure
Volkmanns ischaemic monitoring is a useful adjunct in the diagnosis of raised compartment pressure
contracture; especially when clinical assessment is difficult. The key to a successful outcome is
Fasciotomy; early diagnosis and decompression of affected compartments.
Compartment & 2005 Elsevier Ltd. All rights reserved.
pressure monitoring
Introduction muscle contracture of acute onset with increasing
deformity despite splinting and passive exercises.
Compartment syndrome has been defined as ‘a Compartment syndrome is most commonly seen
condition in which the circulation and function of following trauma, but may occur after ischaemic
tissues within a closed space are compromised by reperfusion injuries,3 burns4 and positioning during
an increased pressure within that space’.1 The surgery 5 Fractures of the tibial shaft and the
muscles and nerves of the extremity are enclosed in forearm account for 58% of compartment syn-
fascial spaces or compartments and are therefore dromes.6 A high index of suspicion is required and
susceptible to this condition. It is a surgical early decompression of all at risk compartments is
emergency which if not recognised and treated the treatment of choice.7–9
early can lead to ischaemic contractures, neurolo-
gical deficit, amputation, renal failure and even
death. Richard von Volkmann was the first to report Pathophysiology
this complication.2 He reported post-traumatic
The common pathogenic factor in compartment
syndrome is increased pressure within a fascial
ÃCorresponding author. Tel.:+44 07968 013803;
compartment. Three theories have been proposed
to explain the development of tissue ischaemia:
fax: +44 208 390 7029.
E-mail addresses: sameer.singh@virgin.net (S. Singh),
ptrikha@doctors.org.uk (S.P. Trikha), mrlewis@totalise.co.uk (1) The increased compartmental pressure may
(J. Lewis). lead to arterial spasm.10
0268-0890/$ - see front matter & 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cuor.2004.12.006

2. ARTICLE IN PRESS
Acute compartment syndrome 469
(2) The critical closing pressure theory states that Table 1 Aetiology of compartment syndrome as
because of the small luminal radius and the high described by Matsen.
mural tension of arterioles there must be a
significant transmural pressure difference (ar- Decreased compartment size
teriolar pressure minus tissue pressure) to Closure of fascial defects
maintain patency. If tissue pressure rises or Tight dressings
arteriolar pressure drops so that this critical Localised external pressure
Increased compartment content
pressure difference does not exist then the
Bleeding
arterioles will close.11 Vascular injury
(3) If tissue pressure rises then the veins will Bleeding disorder
collapse due to their thin walls. If blood Increased capillary permeability
continues to flow from the capillaries the Post Ischaemic swelling
venous pressure will rise until it exceeds tissue Exercise
pressure and patency of the veins is re- Seizure and eclampsia
established. This leads to an increase in venous Trauma
pressure and therefore reduces the arteriove- Burns
nous gradient and as a result reduces tissue Orthopaedic surgery
blood flow.12 Increased capillary pressure
Exercise
Venous obstruction
The response of skeletal muscle to ischaemia or Muscle hypertrophy
trauma is similar regardless of the mechanism of Infiltrated infusion
injury.13 When muscles become anoxic histamine- Nephrotic syndrome
like substances are released and these dilate the
capillary bed and increase endothelial permeabil-
ity. Transudation of plasma occurs into the intra-
muscular compartment and this increases the
pressure within the muscular compartment. To ment syndrome. See Table 1 for a list of aetiologies
compensate the lymphatic drainage increases, as described by Matsen1.
however when this reaches a maximum the
intracompartmental pressure (ICP) causes collapse
of lymphatic vessels.14 Due to the high pressure in
the arterial system there is continuing blood flow Diagnosis
into the compartment and this increases the
swelling and oedema. It is only in the late stages Clinical
of compartment syndrome that arterial flow into
the compartment is compromised. The key to successful treatment of acute compart-
The amount of pressure required to produce a ment syndrome is early diagnosis and decompres-
compartmental syndrome depends on many fac- sion of the affected compartments.1,7,9,23,24
tors, including the duration of pressure elevation, The classical signs of impending compartment
metabolic rate of tissues, vascular tone and the syndrome are pain, pallor, parasthesia, paralysis
mean arterial pressure. and pulselessness (The 5 p’s). However by the time
The data on effects of ischaemia to tissues are all these symptoms have developed (especially
derived from research in which sudden, total pulselessness) the limb will be non-viable.
ischaemia was imposed. Neural tissues demonstrate A high index of suspicion is required to make the
functional abnormalities (parasthesia and hyper- diagnosis. Clinical diagnosis is made on a combina-
esthesia) within 30 min of the onset of ischaemia, tion of physical signs and symptoms. These include
and irreversible functional loss after 12 h.12,15–17 pain out of proportion to the stimulus, pain on
Muscle shows functional changes after 2–4 h and passive stretch of the affected muscle compart-
irreversible changes beginning at 4–12 h.16–18 ment, altered sensation, muscle weakness and
Ischaemia of 4 h gives rise to significant myoglobi- tenderness over the muscle compartment. The
nuria, reaching a maximum at about 3 h although it symptoms and signs which are the most reliable in
can persist up to 12 h.19–22 Compartment syndromes making the diagnosis are increasing pain, and pain
lasting longer than 12 h produce chronic functional on passive stretching of the muscle within the
deficits, such as contractures, motor weakness and affected compartment.25–28 However these symp-
sensory disturbance.23,24 Any cause of increased toms are subjective and impossible to elicit in the
compartmental pressure can result in a compart- unconscious, non-cooperative patient and those

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470 S. Singh et al.
who have had regional blocks. There has been blood leading to inaccurate readings. Due to these
concern raised with the use of patient controlled potential draw backs a solid-state transducer (STIC)
analgesia and regional anaesthesia in high risk intracompartment catheter has been developed.32
cases.28,29 This has a multiperforated polyethylene tip with a
STIC which can remain patent for up 16 h. The STIC
Intracompartmental pressures catheter has been shown to be functionally superior
to conventional systems (needle, wick and slit) and
Pain can be unreliable especially in the trauma easier to assemble, calibrate, maintain and interpret.
patient. It can range from being mild to severe, and The wick, slit and STIC methods require specia-
in the unconscious patient important clinical lised equipment which may not be readily avail-
symptoms and signs can be difficult to elicit. able, while the needle system as proposed by
Techniques have been developed to measure ICPs. Whitesides30 can be constructed from equipment
which is readily available in most hospitals.
If on clinical examination an obvious compart-
Technique for monitoring intracompartmental ment syndrome is present pressure measurement
pressures may not be necessary. However it can be useful
Whitesides 30 introduced a method for measuring adjunct in the diagnosis of compartment syndrome
ICP that required simple equipment available in especially in children, unconscious patients and
most hospitals (Fig. 1). Using a needle, plastic those with equivocal clinical findings.
tubing filled with saline and air attached to a
mercury manometer they established tissue pres-
sure measurement criteria as determinants of the
need for fasciotomy. However this technique At what pressure to decompress?
involved the injection of saline into the compart-
ment and this may aggravate an impending com- The normal tissue pressure within closed compart-
partment syndrome. ments is about 0–10 mmHg. This pressure markedly
The slit and wick techniques require a polyethy- increases in compartment syndrome. There is
lene tubing connected to a pressure transducer. inadequate perfusion and relative ischaemia when
The tubing is filled with water and it is important the tissue pressure within a closed compartment
that there are no air bubbles present within the rises to within 10–30 mmHg of a patient’s diastolic
tubing. The wick and slit catheter allow continuous blood pressure. Whitesides believed that fasciot-
monitoring of compartments, and have been shown omy is indicated when the tissue pressure rises to
to be more accurate than the needle manometer 40 mmHg in a patient with a diastolic pressure of
technique.31 However the end of the tubing in the 70 mmHg. Using these criteria no functional deficits
fascial compartment may become blocked with developed in patients, and all showed conclusive
Figure 1 Apparatus for measuring compartment pressure.

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Acute compartment syndrome 471
evidence of compartment syndrome at the time of clinical studies relate to this region of the body.
operation.30 McQueen 33 recommended a differential The site at which the compartment pressure is
pressure (diastolic pressure minus ICP) of 30 mmHg measured should be within a few centimetres of
as a threshold for fasciotomy in tibial fractures. the maximal pressure as it cannot be assumed that
ICPs between 30 and 50 mmHg have been the ICP equilibrates throughout the compart-
suggested that a fasciotomy should be performed.34 ment.42 The pressure is always highest 5 cm from
The lower level of 30 mmHg is most commonly used the fracture in tibial fractures, and therefore it is
as when the tissue pressure rises above this the recommended that ICP should be measured as close
capillary pressure is insufficient to maintain capil- to the site of injury as possible.43
lary blood flow. It has also been shown that fascial In the lower leg there are four fascial compart-
compliance decreases sharply at an ICP of 33 mmHg ments and one or all of these may be involved in
as the fascia has reached its maximum stretch.35 compartment syndrome. The highest pressures are
It is important to state that tissue viability is recorded in the anterior compartment then the
dependant on adequate perfusion and blood flow deep posterior compartment.9,42 It would seem
within the microcirculation. Setting an absolute logical therefore in tibial fractures to measure the
pressure ignores the role that blood pressure plays pressure within 5 cm of the fracture and to monitor
in maintaining adequate blood flow within a the pressure in the anterior tibial compartment.
compartment. It has been shown that muscle However other compartments may need to be
damage occurring at a specific level relative to monitored depending on the clinical picture.
the blood pressure is more consistent that relying Within the UK practices for monitoring ICP vary.
on a fixed compartment pressure.36 In a postal questionnaire 46% of trauma centres had
The diastolic pressure minus the ICP is called the equipment available for monitoring compartment
delta pressure. The critical level has been found to pressures, and 42% of respondents were unsure at
range from 10 to 35 mmHg. The most commonly what ICP they would perform fasciotomies. Only 9%
used delta pressure is 30 mmHg or less.1,10,33 In used a delta pressure of 30 mmHg as a guide to
tibial fractures it has been shown that by using a perform fasciotomies as suggested by Whitesides 30
delta pressure of 30 mmHg unnecessary fascio- and McQueen.33
tomies can be avoided. No clinically significant Failing to diagnose and treat a compartment
complications were identified in patients with a syndrome urgently can be disastrous for patients.
delta pressure greater than 30 mmHg. Pressure monitoring can be a useful adjunct to help
The ICP or delta pressure at one point in time confirm the diagnosis. McQueen et al. 37 suggest
does not necessarily confirm that a compartment monitoring all patients at risk as an aid to clinical
syndrome is present. During intramedullary nailing diagnosis. Others have suggested that this can lead
there are short increases in ICP, however these are to over treatment.44 Certainly pressure monitoring
not always associated with clinical signs of com- should be used in unconscious patients, those who
partment syndrome.37 The higher the ICP and the are difficult to assess and when equivocal clinical
longer it is maintained the greater the muscle findings are present. All centres involved in trauma
damage, however an ICP of 30 mmHg maintained should have equipment available for monitoring
for 8 h caused significant muscle necrosis in canines compartment pressures and clinicians involved in
35
and biochemical changes have been observed in trauma need to be aware of interpretation of these
the experimental situation with a delta pressure of results.
20 mmHg for 4 h. When the delta pressure ap-
proached zero these changes were present in 2 h.38
As stated earlier the sooner the decompression Other methods for measuring compartment
the better the outcome. If decompression is pressures
delayed for more than 12 h permanent disability
may occur, however if decompression is performed Near-Infrared Spectroscopy (NIRS)
under 6 h of making the diagnosis a full recovery NIRS is an optical technique that allows tracking of
can be expected.24,25,39,40,41 However confirming variations in the oxygenation of muscle tissue.45
the exact time of the start of compartment The technique involves monitoring the absorption
syndrome can be difficult. of light transmitted through muscle tissue at two
distinct wavelengths. A change in the oxygenation
Problems with interpreting pressures state of haemoglobin results in opposite changes in
the absorption of light. By calculating the differ-
The majority of compartment syndromes occur in ences in the absorption signal the device provides a
the lower limb and hence the majority of the continuous index of tissue oxygenation. It can be of

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472 S. Singh et al.
use in investigating chronic compartment syndrome ICP adequate decompressive fasciotomies should be
in adults, as it can detect changes in relative performed.
oxygenation, but it is of little value in acute Several surgical approaches have been tried in
compartment syndrome as changes in the relative the leg. The surgical goal is the prevention of
oxygenation may have already occurred.46 permanent disability, and the adequacy of decom-
pression should not be compromised by cosmesis or
Laser Doppler flowmetry the number and lengths of incisions. It is essential
This uses a flexible fibre optic wire which is to decompress all compartments at risk.
introduced into the muscle compartment. The In the lower limb fibulectomy via a single lateral
signals from this wire are recorded on a computer. incision has been suggested, however this only
It can be used as an adjunct in the diagnosis of allows limited views and an adequate release may
chronic compartment syndrome,47 however it was not be achieved. A two incision approach allows
suggested that further work needs to be carried out safe access to all four compartments of the lower
into the pathophysiology of chronic compartment leg and is the treatment of choice. The deep
syndrome and laser Doppler flowmetry needs posterior compartment has been neglected in
analysis in larger population groups. descriptions of fasciotomies however this is the
2nd most commonly involved compartment and
access can be gained behind the posteromedial
border of the tibia in the distal third of the leg
Treatment where the belly of flexor digitorum longus is
exposed.
Raised ICP threatens the viability of the limb and
The technique of double incision fasciotomy is
this represents a true management emergency. As
described below. It is important to perform a
stated earlier early diagnosis is the key to a
complete decompression and incisions less than
successful outcome.
15 cm may result in inadequate decompression.49 In
Removal of all dressing down to skin, followed by
the emergency treatment of compartment syn-
open extensive fasciotomies with decompression of
drome there is no place for short cosmetic
all muscle compartments in the limb is the
incisions.
treatment of choice.
Experimental evidence shows that the circular
cast can substantiate the adverse effects of raised Lower limb fasciotomy (Fig. 2)
ICP.48 Splitting of the cast on one side led to an Anterolateral incision. This incision allows ap-
average fall in ICP 30%, and 65% if split on both proach to the anterior and lateral compartments of
sides. Splitting of the padding led to a further fall in the leg. A 15–20 cm incision is placed halfway
ICP by 10%. Complete removal of the cast reduced
the pressure by another 15%.
In patients whom the diagnosis is being consid-
ered and in those in whom resuscitation is
proceeding the following steps should be per-
formed:14
(1) Ensure the patient is normotensive, as hypoten-
sion reduces perfusion pressure and facilitates
tissue injury,
(2) Remove any circumferential or constricting
bandages as these may increase ICP,
(3) Maintain the limb at heart level as elevation
reduces the arterio-venous pressure gradient.
(4) Give supplemental oxygen to ensure optimal
saturation.
Figure 2 The safe incisions. These are designed to avoid
Fasciotomies the perforating arteries. The antero-lateral incision is
2 cm lateral to the medial border of the tibia. The
If the tissue pressure remains elevated despite the postero-medial incision is 1 or 2 cm prosterior to the
above, and the clinical scenario indicates increased medial border of the tibia.

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Acute compartment syndrome 473
Figure 3 Anterior and peroneal compartment decom- Figure 4 Decompression of the posterior compartments
pression (ac—anteriror compartment; Ic—lateral com- (s—soleus; g—gastrocneumius; tp—tibialis posterior).
partment). The fascia is shown in dark grey.
between the fibula and the tibial crest. The skin A technique for forearm fasciotomy is now
edges are undermined. A short longitudinal incision described.
is made over the muscle bellies allowing palpation
of the intramuscular septum between the anterior Forearm fasciotomy
and lateral compartments. By identifying the A single incision can be used to decompress the
septum the superficial peroneal nerve can be volar aspect of the forearm (Fig. 5). It is similar to
identified adjacent to the septum where it crosses the volar approach to the radius as described by
the junction of the middle and distal thirds of the Henry.50 It begins 1 cm proximal and 2 cm lateral to
leg. The anterior compartment fascia is opened the medial epicondyle. It is carried obliquely across
throughout the leg by extending the first incision in the antecubital fossa and over the volar aspect of
the fascia (Fig. 3). It is important not to damage the mobile wad of three muscles (brachioradialis,
the superficial peroneal nerve in the distal third of extensor carpi radialis longus and extensor carpi
the wound. The peroneal compartment is decom- radialis brevis). It is curved medially reaching the
pressed by incising the fascia in line with the fibular midline at the junction of the middle and distal
shaft posterior to the intermuscular septum. third of the forearm. It is continued straight distally
Proximally the incision is directed to the fibular to the proximal skin crease over palmaris longus.
head and distally to the lateral malleolus remaining The incision is curved across the wrist crease to the
posterior to the superficial peroneal nerve. mid palm area. The median nerve should be
decompressed at the carpal tunnel. In cases of
Posteromedial incision. This incision is used to median nerve symptoms the median nerve should
decompress the superficial and deep posterior also be explored in the proximal forearm. The
compartments of the leg. It is placed 2 cm posterior median nerve can be constricted at the proximal
to the posterior tibial margin and is about 15–20 cm end of pronator teres and at the proximal edge of
long. Care should be taken to avoid damage to the flexor digitorum superficialis.
saphenous nerve and vein and they should be The dorsal muscle compartment can be released
retracted anteriorly. The superficial posterior com- by a single incision. This begins 2 cm distal to the
partment is decompressed first, and the fascia is lateral epicondyle and carried distally to the wrist.
incised throughout its length (Fig. 4). The Achilles The skin edges are undermined and the dorsal
tendon helps to identify this compartment. The fascia incised directly in line with the skin incision.
fasciotomy is extended distally as far as the medial
malleolus. The deep posterior compartment is then Foot fasciotomies
released by incising the fascia distally and then Excessive bleeding and oedema can produce com-
proximally under the bridge of soleus. It may be partment syndromes in the closed spaces of the
necessary to detach the soleus from the back of foot. Foot compartment syndrome should be
the tibia. suspected in all crushing and high energy foot

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474 S. Singh et al.
wound.53 Closure of the wound takes about 10 days.
There are some commercially available devices to
aid fasciotomy closure.54 The Suture Tension
Adjustment Reel (STAR) is placed parallel to the
wounds at the time of fasciotomy, and when the
swelling has subsided the reels are tightened to
gradually close the wound. This method requires
2–4 days of bedside tightening for wound closure.
Split skin grafting can lead to a poor cosmetic
result, with insensate skin and donor site morbidity.
Delayed primary closure using the skin’s elasticity
provides a more cosmetically acceptable outcome
for the patient but requires greater nursing care.
However a poor cosmetic result is preferable to the
outcome of a missed compartment syndrome.
Figure 5 The incision for decompression of the volar Intramedullary nailing
aspect of the forearm. If posterior compartment pressure
doesn’t concomitantly fall then the posterior compart- Over the last 2 decades intramedullary nailing of
ment requires to be opened by an additional linear tibial fractures has increased. Initially there was
posterior incision. concern that nailing may increase ICPs and pre-
cipitate compartment syndrome and it was thought
that nailing should be delayed for up to 7 days to
allow the swelling to subside.55 Further research in
injuries. With crush injuries of the foot Myerson
this area has shown that during reaming the
found acute compartment syndrome in 16 of 58
pressure may rise to 180 mmHg,37 however this
patients.51 Tense swelling of the foot should alert
high ICP fell back to normal after removing the
the clinician to this possibility, particularly because
reamer. The application of traction also increases
pain on passive stretch of the toes and the presence
ICPs but these immediately dropped with release of
or absence of pedal pulses are less reliable
the traction. Despite high pressures being reached
indications of compartment syndrome in the foot.
during the reduction of tibial fractures and during
There are a number of different approaches to
reaming no patients in the study developed any
decompress foot compartments. A dorsal approach
sequelae of compartment syndrome. Transient
along the 2nd and 4th metatarsals is simple to
increases in compartment pressures seam to be
perform and provides effective decompression of
well tolerated and return back to normal after the
all four compartments.52 Associated Lisfranc in-
stimulus is removed.
juries and metatarsal fractures can also be stabi-
Controversy still exists if monitoring should be
lised via this approach.
performed during intramedullary nailing. McQu-
een9,33 advocates routine monitoring of all patients
with tibial fractures if facilities are available.
Closure of fasciotomy wounds Others have suggested that this may lead to over
treatment44 and unnecessary fasciotomies.
After decompression of fascial compartments the
wounds are left open and sterile dressings are
applied. Delayed primary closure can be performed
when swelling has subsided, however this may be Conclusion
difficult due to skin retraction and oedema. If the
wound edges cannot be approximated without Compartment syndrome can have disastrous con-
tension, skin grafting may be required. sequences if not recognised and treated appro-
Various methods have been described using the priately. In conscious patients the diagnosis can be
elastic properties of the skin to aid fasciotomy made by careful examination of the patient.
closure. Invasive monitoring is a useful adjunct especially
An elastic vessel shoelace can be applied with in unconscious patients and those who are difficult
the staples at the side of the wound. This can be to assess. As the tissue pressure rises the viability of
gradually tightened without the need for anaes- the cells are threatened. The tissue pressure level
thesia, providing gradual closure of the fasciotomy at which perfusion threatens cell viability varies

8. ARTICLE IN PRESS
Acute compartment syndrome 475
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